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General NPI Number Information
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NPI Number | 1467718932
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Entity Type | Individual
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Provider Name | JENNIFER NICOLE LILLEMON M.D.
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Gender | Female
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Dates
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Enumeration Date | 04/09/2012
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Last Update Date | 05/15/2019
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Provider Practice Location Address
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Address Line | 100 E IDAHO ST STE 304
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City | BOISE
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State | ID
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Zip | 83712
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Country | US
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Telephone | 208-381-7040
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Fax |
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Provider Business Mailing Address
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Address Line | 100 E IDAHO ST STE 304
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City | BOISE
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State | ID
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Zip | 83712-6269
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Country | US
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Telephone | 208-381-7040
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207VF0040X
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Taxonomy Name | Urogynecology and Reconstructive Pelvic Surgery (Obstetrics & Gynecology) Physician
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License Number | MD177334
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License Number State | OR
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Taxonomy #2
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Taxonomy Code | 390200000X
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Taxonomy Name | Student in an Organized Health Care Education/Training Program
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License Number |
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License Number State |
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